Comparison of the Effectiveness of Values-Based Behavioral Activation and Mindfulness on Coping Mechanisms in Patients with Diabetes
Keywords:
Values, based behavioral activation model, mindfulness, coping mechanisms, diabetic patientsAbstract
Introduction and Aim: Diabetes is a chronic condition associated not only with physical complications but also with persistent psychological stress that may influence patients’ use of adaptive and maladaptive coping mechanisms. This study aimed to compare the effectiveness of values-based behavioral activation and mindfulness in improving problem-focused coping and reducing emotion-focused and avoidance-focused coping among patients with diabetes.
Methodology: This applied quasi-experimental study employed a pretest–posttest–follow-up design with two intervention groups and one control group. Forty-five women with diabetes attending healthcare centers in Mianeh were purposively recruited and randomly assigned to values-based behavioral activation, mindfulness, or control groups, with 15 participants in each group. Both interventions were delivered in eight group sessions, followed by a two-month follow-up assessment. Coping mechanisms were assessed using the Coping Inventory for Stressful Situations (CISS). Data were analyzed using mixed analysis of variance and Bonferroni post hoc tests in SPSS.
Findings: The between-group effect was significant for problem-focused coping (F=8.711, p=.001), emotion-focused coping (F=8.656, p=.001), and avoidance-focused coping (F=9.573, p=.001). Significant time and time×group interaction effects were also observed for problem-focused coping (F=519.705 and F=140.803), emotion-focused coping (F=203.291 and F=53.808), and avoidance-focused coping (F=252.136 and F=66.320), respectively (p=.001). Bonferroni comparisons indicated that both interventions significantly increased problem-focused coping and significantly reduced emotion-focused and avoidance-focused coping compared with the control group. No significant differences were found between values-based behavioral activation and mindfulness for any coping dimension (p=1.000), and the intervention effects were maintained at the two-month follow-up.
Conclusion: Values-based behavioral activation and mindfulness were similarly effective in promoting more adaptive coping patterns among patients with diabetes. Both interventions may therefore be used as complementary psychological approaches alongside routine medical care to strengthen diabetes-related coping and psychological adjustment.
Downloads
References
Ahmadi, R., Leilabadi, L., & Salehi, M. (2025). Comparison of the effectiveness of acceptance and commitment therapy (ACT) and behavioral activation therapy (BAT) on quality of life and self-care behaviors in patients with type 2 diabetes. International Journal of Education and Cognitive Sciences, 6(4), 1-12. https://doi.org/10.61838/kman.pdmd.513
Alikhah, S., Akbari Govabari, B., & Abolghasemi, A. (2023). The effectiveness of mindfulness-based cognitive therapy on resilience and body image in patients with skin disorders in interaction with emotional reactivity. Islamic Lifestyle Centered on Health, 7(2), 94-103.
Alipour Picha, H., Abbasi, G., & Hassanzadeh, R. (2023). The effect of cognitive behavioral therapy integrated with mindfulness on health anxiety and death obsession in patients with COVID-19. Nursing Management, 12(2), 33-45.
Alvarado-García, P. A. A., Soto-Vásquez, M. R., Infantes Gomez, F. M., Guzman Rodriguez, N. M., & Castro-Paniagua, W. G. (2025). Effect of a mindfulness program on stress, anxiety, depression, sleep quality, social support, and life satisfaction: A quasi-experimental study in college students. Frontiers in psychology, 16, 1508934. https://doi.org/10.3389/fpsyg.2025.1508934
Alwhaibi, M. (2024). Depression, Anxiety, and Health-Related Quality of Life in Adults with Type 2 Diabetes. Journal of clinical medicine, 13(20), 6028. https://doi.org/10.3390/jcm13206028
Azad, M., Bagherzadeh Golmakani, Z., Mansouri, A., & Doustkam, M. (2022). Comparing the effectiveness of behavioral activation and metacognitive therapies on body image concerns, anxiety, and depression in patients with psoriasis. Disability Studies, 12.
Cannon, A., Handelsman, Y., Heile, M., & Shannon, M. (2018). Burden of Illness in Type 2 Diabetes Mellitus. Journal of Managed Care & Specialty Pharmacy, 24, S5-S13. https://doi.org/10.18553/jmcp.2018.24.9-a.s5
Colovic, O., Tosevski, D. L., Mladenovic, I. P., Milosavljevic, M., & Munjiza, A. (2016). Defense mechanisms in "pure" anxiety and "pure" depressive disorders. The Journal of Nervous and Mental Disease, 204(10), 746-751. https://doi.org/10.1097/NMD.0000000000000559
Costa, R. M., Oliveira, G., Pestana, J., Costa, D., & Oliveira, R. F. (2019). Do Psychosocial Factors Moderate the Relation between Testosterone and Female Sexual Desire? The Role of Interoception, Alexithymia, Defense Mechanisms, and Relationship Status. Adaptive Human Behavior and Physiology, 5(1), 13-30. https://doi.org/10.1007/s40750-018-0102-7
Dafei, M., Zarei Mahmoudabadi, H., Dehghani, A., & Moradi Mahmoudabadi, F. (2021). The effect of mindfulness-based cognitive therapy on health-promoting behaviors in students with premenstrual syndrome: A randomized clinical trial. Journal of Mazandaran University of Medical Sciences, 31(197), 65-80.
de Almeida Silva, V., Louzã, M. R., da Silva, M. A., & Nakano, E. Y. (2016). Ego defense mechanisms and types of object relations in adults with ADHD. Journal of Attention Disorders, 20(11), 979-987. https://doi.org/10.1177/1087054712459559
Ee, C. C., Al-Kanini, I., Armour, M., Piya, M. K., McMorrow, R., Rao, V. S., & Sabag, A. (2025). Mindfulness-based interventions for adults with type 2 diabetes mellitus: A systematic review and meta-analysis. Integrative Medicine Research, 14(2), 101138. https://doi.org/10.1016/j.imr.2025.101138
Egede, L. E., Davidson, T. M., & Knapp, R. G. (2021). HOME DM-BAT: Home-based diabetes-modified behavioral activation treatment for low-income seniors with type 2 diabetes—study protocol for a randomized controlled trial. Trials, 22, 787. https://doi.org/10.1186/s13063-021-05744-1
Farooqi, A., Gillies, C., Sathanapally, H., Abner, S., Seidu, S., Davies, M. J., Polonsky, W. H., & Khunti, K. (2022). A systematic review and meta-analysis to compare the prevalence of depression between people with and without Type 1 and Type 2 diabetes. Primary Care Diabetes, 16, 1-10. https://doi.org/10.1016/j.pcd.2021.11.001
Fisher, V., Li, W. W., & Malabu, U. (2023). The effectiveness of mindfulness-based stress reduction (MBSR) on the mental health, HbA1C, and mindfulness of diabetes patients: A systematic review and meta-analysis of randomised controlled trials. Applied Psychology: Health and Well-Being, 15(4), 1733-1749. https://doi.org/10.1111/aphw.12441
Garland, E. L., Farb, N. A., Goldin, P. R., & Fredrickson, B. L. (2015). The mindfulness-to-meaning theory: Extensions, applications, and challenges at the attention-appraisal-emotion interface. Psychological Inquiry, 26, 377-387. https://doi.org/10.1080/1047840X.2015.1092493
Ghaem Magham Farahani, Z., Rahimian Boogar, E., Najafi, M., Foroughoddin Adl, A., & Dabiri, S. (2012). Comparing the effects of group behavioral activation with and without family support on reducing anxiety in patients with coronary heart disease. Behavioral Sciences Research, 10(2), 79-89.
Godage, P., Giggins, O. M., Doyle, J., & Byrne, A. (2026). Integrating psychological support into gestational diabetes self-management: Development of a user-centred digital mindfulness programme. Women's Health, 22, 17455057261473448. https://doi.org/10.1177/17455057261473448
Hamasaki, H. (2023). The effects of mindfulness on Glycemic Control in people with diabetes: An overview of systematic reviews and meta-analyses. Medicines, 10(9), 53. https://doi.org/10.3390/medicines10090053
Hayes, S. C., & Strosahl, K. D. (2010). A Practical Guide to Acceptance and Commitment Therapy. Springer Science and Business Media Inc.
Ho, M. T. H., Chan, J. K. N., Chiu, W. C. Y., Tsang, L. L. W., Chan, K. S. W., Wong, M. M. C., & Chang, W. C. (2025). Risk of mortality and complications in patients with severe mental illness and co-occurring diabetes mellitus: A systematic review and meta-analysis. European Neuropsychopharmacology, 91, 25-36. https://doi.org/10.1016/j.euroneuro.2024.11.002
Hyphantis, T. N., Taunay, T. C., Macedo, D. S., Soeiro-de-Souza, M. G., Bisol, L. W., Fountoulakis, K. N., Lara, D. R., & Carvalho, A. F. (2013). Affective temperaments and ego defense mechanisms associated with somatic symptom severity in a large sample. Journal of affective disorders, 150(2), 481-489. https://doi.org/10.1016/j.jad.2013.04.043
Iglay, K., Hannachi, H., Joseph Howie, P., Xu, J., Li, X., Engel, S. S., Moore, L. M., & Rajpathak, S. (2016). Prevalence and co-prevalence of comorbidities among patients with type 2 diabetes mellitus. Current Medical Research and Opinion, 32, 1243-1252. https://doi.org/10.1185/03007995.2016.1168291
Jiang, S., Pan, X., Li, H., & Su, Y. (2024). Global trends and developments in mindfulness interventions for diabetes: A bibliometric study. Diabetology & Metabolic Syndrome, 16(1), 43. https://doi.org/10.1186/s13098-024-01288-x
Kanter, J. W., Puspitassari, A., Santos, M., & Nagy, G. (2014). Social work and behavioral activation. In M. S. Boone (Ed.), Mindfulness and acceptance in social work (pp. 101-122). New Harbinger Publications.
Khadem Hosseini, M., Merati, A., Piryaei, H., & Roshanaei, K. (2024). Comparing the effectiveness of bibliotherapy, behavioral activation therapy, and mindfulness-based cognitive therapy on psychological distress in women with type 2 diabetes: A quasi-experimental study. Journal of Nursing and Midwifery, 22(2), 146-160.
Khajehzadeh, P., & Sabahi, P. (2021). The effectiveness of mindfulness training on emotion regulation and distress tolerance in nonclinical obsessive-compulsive samples. Clinical Psychology.
Kordani, S., & Dashtbozorgi, Z. (2022). The effect of positive mindfulness training on health anxiety, happiness, and health adjustment among nurses during the COVID-19 pandemic. Psychiatric Nursing, 10(3), 53-64.
Mahmoudzadeh, S., & Rajabi, S. (2022). Comparing mindfulness and health anxiety in women with breast cancer and healthy individuals. Health System Research, 18(4), 314-320.
Marais, G. A. B., Lantheaume, S., Fiault, R., & Shankland, R. (2020). Mindfulness-Based Programs Improve Psychological Flexibility, Mental Health, Well-Being, and Time Management in Academics. European Journal of Investigation in Health, Psychology and Education, 10(4), 1035-1050. https://doi.org/10.3390/ejihpe10040073
McCauley, E., Schloredt, K. A., Gudmundsen, G. R., Martell, C. R., & Dimidjian, S. (2016). Behavioral activation with adolescents: A clinician's guide. Guilford Publications.
Mersha, A. G., Tollosa, D. N., Bagade, T., & Eftekhari, P. (2022). A bidirectional relationship between diabetes mellitus and anxiety: A systematic review and meta-analysis. Journal of psychosomatic research, 162, 110991. https://doi.org/10.1016/j.jpsychores.2022.110991
Milani, I., Carreno Dextre, G. A. L., Elisei, R. F., Ripa, P., Capatti, S. R., Magon, A., & Caruso, R. (2025). Educational programs and mental health outcomes in individuals with type 1 diabetes: A scoping review. Acta Diabetologica, 62(11), 1843-1857. https://doi.org/10.1007/s00592-025-02580-6
Moshier, S. J., & Otto, M. W. (2017). Behavioral activation treatment for major depression: A randomized trial of the efficacy of augmentation with cognitive control training. Journal of affective disorders, 210, 265-268. https://doi.org/10.1016/j.jad.2017.01.003
Naik, A. D., Hundt, N. E., & Vaughan, E. M. (2019). Effect of Telephone-Delivered Collaborative Goal Setting and Behavioral Activation vs Enhanced Usual Care for Depression Among Adults With Uncontrolled Diabetes: A Randomized Clinical Trial. JAMA Network Open, 2(8), e198634. https://doi.org/10.1001/jamanetworkopen.2019.8634
Okajima, I., Kunisato, Y., Nakajima, S., & Takagaki, K. (2011). Behavioral activation treatment of depression: Conceptual overview and meta-analysis of recent evidence. Japanese Psychological Review, 54, 473-488.
Rabiepour, F., Hosseini Nasab, S. D., & Salari, A. (2022). Comparing the effectiveness of cognitive rehabilitation therapy and mindfulness-based therapy on anxiety in patients with hypertension: A randomized clinical trial. Disability Studies, 12.
Rezapour, H., Bahramipour Isfahani, M., & Torkan, H. (2023). Comparing the effectiveness of behavioral activation and state relaxation therapies on antisocial core beliefs and social problem solving in male adolescents with high social anxiety. Social Psychology Research, 13(50), 77-92.
Rizzo, J. M., & Schwartz, R. C. (2021). The effect of mindfulness, psychological flexibility, and emotional intelligence on self-efficacy and functional outcomes among chronic pain clients. Journal of Contemporary Psychotherapy: On the Cutting Edge of Modern Developments in Psychotherapy, 51(2), 109-116. https://doi.org/10.1007/s10879-020-09481-5
Shojaei, F., Jabal Ameli, S., Latifi, Z., & Siavash, M. (2022). Comparing self-healing and cognitive behavioral therapy integrated with mindfulness on health-promoting lifestyles in patients with type 2 diabetes: A clinical trial. Journal of Gorgan University of Medical Sciences, 24(3), 8-16.
Simonsson, O., Fisher, S., & Martin, M. (2021). Awareness and experience of mindfulness in Britain. Sociological Research Online, 26, 833-852. https://doi.org/10.1177/1360780420980761
Skjelbred, T., Warming, P. E., Behr, E. R., Køber, L., Pedersen-Bjergaard, U., Winkel, B. G., & Tfelt-Hansen, J. (2026). Diabetes and sudden cardiac death: A Danish nationwide study. European Heart Journal, 47(21), 2644-2656. https://doi.org/10.1093/eurheartj/ehaf826
Takagaki, K., Okamoto, Y., Jinnin, R., Yokoyama, S., Yoshino, A., & Kagawa, F. (2018). Effects of behavioral activation program without psychotropic medication treatment for depression in late adolescence: Case report. Neuropsychiatric Disease and Treatment, 14, 2159-2164. https://doi.org/10.2147/NDT.S168077
Tindall, L., Mikocka-Walus, A., McMillan, D., Wright, B., Hewitt, C., & Gascoyne, S. (2017). Is behavioural activation effective in the treatment of depression in young people? A systematic review and meta-analysis. https://doi.org/10.1111/papt.12121
Tomic, D., Shaw, J. E., & Magliano, D. J. (2022). The burden and risks of emerging complications of diabetes mellitus. Nature Reviews Endocrinology, 18, 525-539. https://doi.org/10.1038/s41574-022-00690-7
Tsai, C. C., Yu, H. I., & Chen, M. F. (2025). The Effectiveness of a Mindfulness-Based Healthy Lifestyle Program for Older Adults With Type 2 Diabetes. Journal of Applied Gerontology, 07334648251395792. https://doi.org/10.1177/07334648251395792
Wang, H., Ge, L., Yan Yan Kwok, J., Zhang, Z., Wiley, J., & Guo, J. (2025). A blended mindfulness-based stress reduction program to improve diabetes self-management among people with type 2 diabetes mellitus: A mediation effect analysis. Annals of Behavioral Medicine, 59(1), kaae075. https://doi.org/10.1093/abm/kaae075
Wright, S., Crewe, B., & Hulley, S. (2017). Suppression, denial, sublimation: Defending against the initial pains of very long life sentences. Theoretical Criminology, 21(2), 225-246. https://doi.org/10.1177/1362480616643581
Zheng, Q., & Yang, W. (2024). Intervention study on the impact of internet-based mindfulness meditation on depression and anxiety among university students. International Journal of Education and Humanities, 16, 224-228. https://doi.org/10.54097/9mfb3q15
Downloads
Publication Timeline
- Submitted
- Revised
- Accepted
Issue
Section
License
Copyright (c) 2025 Arezo Safaryani (Author); Alireza Jafari; Mehrdad Sabet (Author)
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
